Chronic lymphocytic leukemia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shalinder Singh, M.B.B.S.[2]

Overview

The mainstay of treatmen for symptomatic chronic lymphocytic leukemia patients is immunochemotherapy. Asymptomatic chronic lymphocytic leukemia patients are managed with observation and follow up, whereas symptomatic chronic lymphocytic leukemia patients are treated with immunochemotherapy. Immunochemotherapies used for the treatment of chronic lymphocytic leukemia patients include purine analogues, alkylating agents, monoclonal antibodies, corticosteroids, tyrosine kinase inhibitors, and B-cell receptor pathway inhibitors. Radiation therapy is not recommended for the management of chronic lymphocytic leukemia patients.

Immunochemotherapy

  • The mainstay of treatment for symptomatic chronic lymphocytic leukemia patients is immunochemotherapy.
  • Asymptomatic chronic lymphocytic leukemia patients are managed with observation and follow up, whereas symptomatic chronic lymphocytic leukemia patients are treated with immunochemotherapy.[1]
  • Indications to initiate immunochemotherapy among patients with chronic lymphocytic leukemia include:[2]
  • Fever of unknown origin (>38.1°C for a period greater than two weeks)
  • Night sweats for ≥ one month
  • Unintentional significant weight loss (≥10%) over a period of six months
  • An increase of greater than 50% over a 2-month period
  • A lymphocyte doubling in a period shorter than six months
  • Immunomodulatory agents such as:
  • The optimal immunochemotherapeutic regimen used for the management of chronic lymphocytic leukemia patients depends on a number of factors which include:
  • The algorithm below summarizes the management approach for chronic lymphocytic leukemia patients:[12][13][14]


 
 
 
 
 
Initial patients evaluation
 
 
 
 
 
 
 
 
 
 
History
Physical examination
Complete blood count
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Staging
 
 
 
 
 
 
Rai Staging System
Binet Staging System
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rai stage 0-2
Binet stage A
 
Rai stage 3-4
Binet stage B-C
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients managed by observation and close follow-up
 
Evaluate patients by Cumulative Index Illness Rating Scale
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fit patients (CIRS <6)
 
Frail patients (CIRS ≥6)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FISH chromosomal analysis
 

Obinutuzumab AND chlorambucil
Ofatumumab AND chlorambucil

Rituximab AND chlorambucil
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunochemotherapeutic regimens for the management of patients without chromosome 17p deletion or chromosome 11q deletion can be found here
 
Immunochemotherapeutic regimens for the management of patients with chromosome 17p deletion can be found here
 
Immunochemotherapeutic regimens for the management of patients with chromosome 11q deletion can be found here
 


Immunochemotherapeutic Regimens for the Management of Patients WITHOUT Chromosome 17p Deletion or Chromosome 11q Deletion

First Line Therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age (or younger than 70 years of age with a poor performance status) include (in order of preference):[15][16][17][18]
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age with a good performance status include (in order of preference):[19][20][21][22][23]

Refractory/Relapsed Therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age (or younger than 70 years of age with a poor performance status) include (in order of preference):[24][25][26]
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age with a good performance status include (in order of preference):[27][28][29]

Immunochemotherapeutic Regimens for the Management of Patients WITH Chromosome 17p Deletion

First Line Therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients regardless the age group include (in order of preference):[30][31][32][33][34]

Refractory/Relapsed Therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients regardless the age group include (in order of preference):

Immunochemotherapeutic Regimens for the Management of Patients WITH Chromosome 11q Deletion

First Line Therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age (or younger than 70 years of age with a poor performance status) include (in order of preference):[35]
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age with a good performance status include (in order of preference):[36][37]

Allogeneic stem cell transplantation

Supportive Therapy

Opportunistic Infections Prophylaxis

  • Other strategies for the prevention of opportunistic infections include:

Autoimmune Cytopenia Prophylaxis

Thromboprophylaxis

Radiation Therapy

References

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